Are you billing correctly for nurse practitioners and physician assistants?

June 18, 2018

Are you billing correctly for nurse practitioners and physician assistants?


Allergy practices are increasingly hiring nurse practitioners (NPs) and physician assistants (PAs) to grow practice revenue and improve allergist satisfaction and patient care. If you’re among them, you’ll want to make sure you’re billing for them correctly and maximizing potential revenue for your practice.

Not surprisingly, Medicare sets the rules for how to bill for advanced practice providers (APPs), which include NPs and PAs. Medicare provides two billing options for services provided by APPs:

1. Bill under the APP’s own National Provider Identifier (NPI).

  • Under Medicare, this results in a 15% reduction in reimbursement from the physician fee schedule.
  • The downside is a reduction in reimbursement. The upside is APPs have greater flexibility, including seeing new patients and existing patients with new problems.

2. Bill “incident to,” which means billing under the supervising allergist’s NPI.

  • Under Medicare, when billing “incident to,” you will receive 100% of Medicare rates.
  • Reimbursement is higher, but you must meet the following requirements:
    • The allergist must perform the initial service and initiate any changes in the care plan. So, APPs can’t see new patients or existing patients with new problems, and bill “incident to.”
    • The allergist must be present in the office suite and available during the time the care is given. So, if an APP is the only provider seeing patients on a Saturday or at a remote location, she can’t bill “incident to.”
    • The allergist must actively participate in and manage the patient’s treatment.
  • One side note: the allergist who initiates the plan of care does not need to be the same allergist who supervises the NP – it can be another allergist in the group. 

Most commercial payers follow Medicare’s “incident to” rules. But plans vary, so check your contracts to review the rules for “incident to” billing. Some commercial plans have less restrictive rules regarding “incident to” billing – but make sure you get them in writing.

So how can you decide whether “incident to” billing makes sense for your practice? Here are some things to consider:

  • How do APPs work in your practice? Do they see only follow up patients and cover allergy shots, and is there always an allergist in the clinic with them? If so, “incident to” billing might work. However, if your APPs cover remote locations by themselves, or regularly see new patients, billing “incident to” won’t work.
  • Check your state’s licensing and scope of practice regulations to identify other requirements.

Wondering how other allergy practices handle this? A quick poll of the Practice Management Committee showed the following:

  • In one practice with 11 APPs, nine of them bill “incident to” and two of them work independently and bill under their own NPIs.
  • In another practice with several APPs, all of them bill under their own NPIs.
  • A third practice bills both ways, depending on the circumstances. According to Michael Rupp, MD, FACAAI, member of the Practice Management Committee, “We bill “incident to” whenever possible, but we make sure it meets incident to criteria. We bill under the NP’s NPI when they see patients with new complaints or when one of us is not available.” 
  • In a fourth practice, all APPs bill Medicare under their own NPI. J. Kelly Davis, BS, CMPE, member of the Practice Management Committee, notes, “More commercial payors are requiring APPs to be credentialed separately and bill under their own NPI.”

APPs can really benefit your allergy practice and your patients. Make sure you’re billing for their services properly and maximizing your reimbursement.